| NPI | 1073125563 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0020917) | 
| Additional Taxonomies | 225100000X Physical Therapist (Licence: DC PT872659) | 
| Enumeration Date | 2020-08-18 | 
| Last Update Date | 2025-10-10 |